Judy Pilgrim smells a shirt that belonged to her son Lance at her home in Daingerfield. Two bags of his belongings have remained unpacked since he returned with them from the Waco VA medical center in August 2007. Two days later, he died of a drug overdose. Photo: Jay Janner

Lance Pilgrim attended college after graduating high school in this small Northeast Texas town an hour from the Arkansas and Louisiana borders. But drawn to heavy machinery by his father’s work as a mechanic at the local coal mine, he decided to follow a similar path in the military. In October 2000, he joined the Army.

Assigned to Korea, Pilgrim wrote letters home that reflected a deep contentment. “It was so serene last night, mamma, i don’t think i can even put it in to words,” he wrote on New Year’s Eve 2001. “He loved it,” his father, Randy, said.

When the U.S. invaded Iraq in March 2003, Pilgrim was with the first soldiers deployed, the 3rd Infantry. When he returned four months later, his mother, Judy, said, “He had a different look in his eyes — a really deep sadness.”

He talked about quitting. Later that summer, after Pilgrim broke his finger in a pickup football game at Fort Sill, Okla., an Army doctor prescribed OxyContin for the pain. Use of the powerful narcotic baffled his mother: “You gave him this stuff for a broken finger?”

Getting refills was easy, she added, and it wasn’t long before Pilgrim began abusing the painkiller. “He found out very quickly he could deal with his mental health symptoms with the drugs,” Judy said.

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Pilgrim ended up going AWOL four times; eventually, he was discharged from the Army. Over the next two years, he shuttled in and out of various treatment centers.

In August 2007, a month into an inpatient treatment program for post-traumatic stress disorder in Waco, Pilgrim was kicked out for fighting. Despite his history of drug abuse, he was sent home with a prescription for hydrocodone, another opiate painkiller.

Two days later, on Aug. 18, six days before his 27th birthday, his body was discovered in a room at the Relax Inn, a single-story, stucco motel within sight of the high school stadium where he’d played football. The autopsy showed a lethal level of hydrocodone and methadone. His death was ruled accidental.

But it was not unique. An American-Statesman investigation has found that, among the state’s veterans of the operations in Iraq and Afghanistan receiving disability benefits when they died, an astonishing percentage succumbed to drug overdoses or toxic combinations of prescription drugs.

The deaths weren’t simple to document. Information released by the U.S. Department of Veterans Affairs showed only that 345 Texas veterans of the two conflicts who received VA benefits had died between 2003 and 2011; it did not reveal names or how they died. The Statesman was able to identify and establish causes of death for 266, or 77 percent.

Of those, nearly 1 in 5 was killed by the toxic effects of drugs. Virtually all the deaths were ruled accidental; only two of the former service members wrote suicide notes.

The Statesman’s analysis expands and adds important details to the meager research on overdoses among recent veterans. Amy Bohnert, a University of Michigan and Department of Veterans Affairs researcher, published the first systemic examination of the phenomenon only last year.

“I was surprised there wasn’t more” research on the subject, she said in an interview. “It’s a concerning issue.”

Among all veterans receiving VA services nationally in a single year, 2005, she calculated 1,013 had died of accidental drug overdoses — double the rate of the civilian population, when accounting for age and gender. Her surprising conclusion: When compared to civilian rates, overdoses are a greater threat to veterans than suicides, which have been far more publicized.

And the Statesman’s analysis suggests that among Iraq and Afghanistan veterans, overdoses may be even more prevalent than among the full veteran population Bohnert studied.

Prescribed pills

A review of the Texas veterans’ autopsy and medical examiner reports shows that only a handful of the overdoses were attributable solely to illegal drugs.

The remainder of the drug-related deaths identified by the newspaper were caused by prescription medications — pills dispensed by physicians to dull pain, promote sleep and treat mood disorders such as depression and anxiety. Bohnert’s study also identified prescription drugs as those most commonly linked to veteran overdoses.

Three of the 47 overdoses were ruled suicides. The rest were determined to be accidents — fatal miscalculations of dosages, or a tragic failure to account for the deadly interactions among multiple drugs.

“Those numbers are even higher than we expected,” said Kim Ruocco, a counselor for Virginia-based Tragedy Assistance Program for Survivors, which provides support services to family members of military fatalities. “It’s an extremely important piece of the picture, and people are not talking about it.”

The oldest Texas veteran to die from prescription pills was Ray Rivas, who passed through both Iraq and Afghanistan during his Army career. He was 53 when, sitting in his car in the parking lot outside of San Antonio’s Brooke Army Medical Center three years ago, his body shut down from the toxic effects of Ambien sleeping pills. His death was determined to be a suicide.

The youngest fatality was Clint Dickey, an ex-Army veteran registered as a student at Texas A&M University when he ingested a toxic dose of oxycodone in February 2010 at his College Station home. He was 22 years old.

The average age of the Texas military veterans who died from drug overdoses was 29. Three were women.

It is unclear how many of the legal pills directly responsible for the veterans’ deaths were prescribed by VA doctors. Interviews with survivors suggest some were. But many of the service members were initially prescribed the medications during their active duty as treatment for physical and mental injuries sustained during their service, family members said.

Some were taking so many of the drugs that identifying precisely which medicine was responsible for killing them was not possible.

Austin’s Chad Everett Mitchell, a 40-year-old Navy veteran who served seven overseas tours, from the Persian Gulf to Iraq, died two years ago literally surrounded by pills. “Due to the extreme amount of medications present, the medications could not be individually inventoried on scene,” the Travis County medical examiner’s report noted.

More legal drugs

The military has struggled with drugs during every conflict. Many Vietnam combatants famously returned home with heroin addictions, fallout from use in Southeast Asia.

Today’s fighting men and women are more at risk from the drugs given to them legally. A 2010 Army study found that one-third of its soldiers were on prescription meds, and nearly half of those — 76,500 soldiers — were taking powerful and addictive opiate painkillers.

The Iraq and Afghanistan conflicts have swelled the ranks of injured service members. Nearly half returning from their deployments complain of pain-related problems.

Medical advances also mean many more are surviving serious injuries, further increasing the demand for drugs to control pain. In 2009, military doctors wrote 3.8 million prescriptions for narcotic pain pills — four times as many as they did in 2001. The Army also reported the number of amphetamine prescriptions doubled between 2006 and 2009, much of it because of the rising number of soldiers diagnosed with adult attention deficit hyperactivity disorder.

More drugs have meant more drug problems among service members. “Access to prescription pain medication puts them at higher risk for addiction and abuse of these substances than the civilian population,” a 2012 report on prescription drug misuse stated.

A 2008 survey showed prescription drug abuse among military personnel doubled from 2002 to 2005 and then nearly tripled again over the next three years, the growth primarily attributable to the misuse of pain medications. Studies of active-duty soldiers have found that what the Army study termed a “permissive climate of prescription medication use” posed a direct threat to soldiers’ health.

Indeed, between 2006 and 2009, the Army reported 139 soldiers’ accidental deaths involved prescription drugs. About one-third of Army suicide victims used prescription drugs to kill themselves.

Evidence suggests many Iraq and Afghanistan veterans continue to struggle with drug misuse after they leave the service.

A 2010 U.S. Government Accountability Office report calculated that 420,000 of 5 million veterans from all wars receiving treatment from the VA had been identified as having substance abuse disorders.

Last year, a study of more than 450,000 Iraq and Afghanistan veterans found that 4.5 percent had a drug abuse disorder diagnosis — more than double the civilian rate — adding that the rate was likely even higher because of the VA’s poor screening process. The same study found that “funding for VA substance abuse treatment programs has declined relative to other healthcare services.”

Over the past decade, the use of powerful opioid painkillers dispensed by VA doctors to treat retired military members has soared, according to data the Statesman acquired from the agency through the federal Freedom of Information Act.

Between 2002 and 2011, total prescriptions written by VA physicians rose 37 percent. Over that same period, the number of prescriptions VA doctors wrote for oxycodone rose 150 percent. Prescriptions for methadone, once used mainly to help wean addicts off heroin but more recently prescribed as an inexpensive painkiller, nearly tripled from 2002 to 2009 before dropping back slightly over the past two years.

The VA’s use of hydrocodone — often mixed with acetaminophen under the brand name Vicodin — has exploded over the past decade.

Data from IMS Health, a health care information company, show the number of hydrocodone/acetaminophen prescriptions written by U.S. physicians for civilians rose 68 percent from 2002 to 2011. Prescriptions of the drug written by VA doctors climbed 360 percent during the same period.

'It isn’t shocking’

Those who work closely with service members say that the high incidence of drug poisoning deaths the Statesman found among Texas veterans is not a surprise.

The VA, too, says it is keenly aware of former service members’ drug battles, which are part of a larger trend. “Our society is now challenged with this very alarming data,” Robert Kerns, the VA’s national program director for pain management, said in an interview.

Kerns said the VA has been a pioneer and leader in its use of painkillers, always basing its protocols on the best available medical information — although, in retrospect, some of that information turned out to be wrong. “The zeitgeist was that opioids were a largely safe treatment approach that should be offered to large numbers of patients with pain,” he said. “Twelve years later, I think we’ve learned that’s not the case.”

Kerns said he expects more current statistics on VA prescriptions to reflect a decreasing reliance on the powerful painkillers. Using new guidelines, “we’re trying to promote their safe use,” he said, adding that a large-scale program to train mental health providers to use cognitive behavioral therapy and other nonmedication treatments, sooner, for chronic pain is underway.

VA doctors “are encouraged to think about opioids not necessarily as a last step, but second- or third-tier steps to pain management,” he said.

There have been successes. Use of benzodiazepines, addictive medications that are used to treat anxiety and that can interact fatally with narcotics, are down. At the Wounded Warrior Clinic at Walter Reed Army Medical Center, the percentage of patients on prescription painkillers dropped 83 percent in 2008 to about 10 percent last year. Newer VA protocols urge regular urine tests to identify veterans at risk of drug abuse and close monitoring of those on the pills, and they have limited the length and number of pain prescription refills.

Yet studies also have shown the military and VA still struggle with how best to balance the benefits and risks of powerful prescription drugs. As late as 2010, an Army report on pain treatment noted that “the number of prescriptions written for pain medications has increased and the correlation between suicide and prescription pain medication abuse is of deep concern to” the Department of Defense.

It also noted the military continued to do a poor job screening patients whose mental conditions put them at greater risk of drug abuse: “There is no routine or standardized screening for those at risk, nor is there a system to share this information. ... In other words, there is no reliable means of connecting the dots.”

And while the VA has regularly updated its guidelines for treating veterans’ pain to minimize the risks associated with prescription medications, there remain wide variations within the sprawling agency in how closely they are followed. “Some hospitals are doing a great job instituting safety policies,” said Jodie Trafton, a VA researcher based in Menlo Park, Calif. “And there are others where it’s pretty lax.”

Last month, the VA’s Office of Inspector General found that physicians at a Maine VA clinic didn’t properly monitor their patients on opioids. In some cases, they ignored positive drug tests or prescribed the painkillers to patients whom they had not seen. Rather than reassess the opioid users every few months, some patients were not re-evaluated for more than a year.

There are other gaps the VA has limited ability to close. Outpatients can seek drugs outside the VA, and the multiple prescriptions can be deadly.

Chad Mitchell began using a private pain clinic in Austin in 2009 because he said his VA doctors were not providing adequate care for unrelenting pain related to a complicated operation to remove a tumor from his chest a year earlier, recalled his wife, Kimberly. He also had pain from injuries sustained during his service. She added that even she was unaware of the extent of his use of the narcotics: “He was in a lot of pain, but he hid it from people.”

Medical records reviewed by the Statesman show that in the weeks before he died, Mitchell, who also had screened positive for PTSD, was written prescriptions for OxyContin, methadone, Endocet and morphine by four physicians in the Austin pain clinic and a VA doctor — nearly 600 opiate pain pills in all. “If there had been communication (between the doctors), we wouldn’t be having this conversation now,” his wife said.

Another lost son

Five years after his death, Lance Pilgrim still occupies his parents’ home. They are raising his 12-year-old son. His mother, Judy, keeps several bags of his clothes in his old bedroom. Occasionally, she’ll deeply inhale his fading smell. An answering machine on the kitchen counter contains the last reminder of Pilgrim’s voice. “I love you,” he can be heard saying.

The first hint their son was struggling came within hours of his return from Iraq on June 14, 2003, a month after President George W. Bush declared “mission accomplished.” Pilgrim called his mother in the middle of the night to tell her he was having bad dreams and needed to hear her voice. “He’d never had nightmares before,” she said.

Pilgrim went AWOL that October; his father, Randy, found him sleeping behind a dumpster. He returned to Fort Sill but walked away a week later.

After a stay at a Wichita Falls hospital that treats behavioral and substance abuse disorders, he returned to his post. But after he left again — and was picked up with marijuana — the Army gave Pilgrim an other-than-honorable discharge in 2004.

He found work, mostly in construction, but struggled to hold a job; nightmares kept him awake, so he overslept. Loud noises panicked him. Over the next three years, he shuttled in and out of VA hospitals.

“We’d take him in, and they’d keep him for a few days, but nothing stuck,” Judy said.

In July 2007, Pilgrim was admitted to a special PTSD treatment program in Waco. After a scuffle with another patient, he was sent home Aug. 16 with a prescription for hydrocodone with two refills, the bottle showed. Two days later, he was discovered dead of an overdose.

As her son added tattoos over the years, Judy had observed that his body was roughly divided in two. On one side, he’d printed his home address and his son’s birthday. “And the other side was just evil images,” she said. “It was like a battle.” Just before he died, he’d added a drawing of spider’s web on his arm. “It’s what I feel I’m trapped in,” he’d said.

Because of his discharge status, Pilgrim was buried without military ceremony at the Daingerfield cemetery Aug. 22, 2007. His father was furious.

“This young man fought for his country and came back with a problem, and they were sweeping it under the rug,” he said.

Two years later, the Army upgraded Pilgrim’s discharge to honorable. “The overall length and quality of the applicant’s service, to include the combat service, and the supporting medical documents from the Veterans Administration, mitigated the discrediting entries in the service record,” the decision read.

In 2010, the Pilgrims filed a lawsuit charging the VA with negligence for prescribing hydrocodone to their son. They later settled it at mediation, obtaining a small fund for Pilgrim’s son’s education.

“What we wanted was for the VA to take notice — that they did something wrong,” his mother said. “I thought we’d finally get the chance to sit down across from the doctor and say, 'How could you do this?’ ”